The spinal cord is part of the Central Nervous System (CNS), which consists of the brain and spinal cord. The Central Nervous system is responsible for receiving, integrating, and responding to environmental information. In addition, the CNS keeps our hearts beating, our lungs breathing, as well as metabolic processes functioning (involuntary functions). The CNS executes all muscle movement needed for accomplishing activities of daily life, feeding, dressing, toileting, bathing, transferring, and continence (voluntary function).
The spinal cord consists of nerve tissue fibers that extend from the brainstem and terminate at the caudal equina. The nerve tissue fibers are encased by bone, called vertebrae which protect the spinal cord, as well as provide attachment for muscles and tendons, some of these muscles transverse part or all of the spinal column which holds the spine erect.
There are 24 vertebrae in the spine, in addition to the sacrum (the sacrum is the bony structure at the base of the lumbar vertebrae which is part of the pelvis). Vertebrae are divided into three primary sections, cervical, thoracic, and lumbar and identified by their location in the spinal column. The cervical spine has seven vertebrae numbered one through seven with one being the closest vertebra to the cranium labeled C1. The thoracic spine is composed of 12 vertebrae, numbered one through 12 with T1 being the closet vertebrae to the cervical spine. The five lumbar vertebrae are the lowest vertebrae in the spinal column, numbered one through five with L1 being the closest vertebrae to the thoracic spine.
As the nerve fibers travel down the spinal column, nerves branch away at each level of the spinal column, serving a specific corporal function. In the cervical spine, the cervical nerves exit above their corresponding vertebrae, except for C8, this exits below C7. The lower in the spinal column that the nerves exit, the lower the muscular innervation. Nerves exiting the cervical spine are responsible for upper extremity movements and nerves exiting the lumbar spine are responsible for lower extremity movement.
When an injury occurs to the spinal cord, the significance of the injury is dependent on the level of injury. The higher in the spinal column the damage occurs the more severe the injury. Loss of function occurs not only at the site of injury but everything below the level of injury is compromised. If there is damage at the C5 level, both the upper and lower extremities are affected. Damage to the lumbar spine will affect the lower extremities but not the upper extremities. The injury may be complete or incomplete. A complete spinal cord injury results when the spinal cord is completely severed resulting in the brains inability to send signals at and below the level of injury. An incomplete injury is identified as some function or feeling below the site of injury.
Loss at the higher levels of the cervical spine, is the most severe of the spinal cord injuries, resulting in paralysis of the arms, hands, trunk, and legs (quadriplegia). Injuries at C1 – C4, may result in difficulties breathing and communicating. The individual would require 24-hour/day personal care, complete assistance with activities of daily living, such as eating, dressing, bathing, and toileting. If the injured person is able to operate a wheelchair the chair would require special controls to move the chair independently. Assistance will be needed for transferring in and out of the chair. The person with a spinal cord injury will require a special, adapted van with special controls if they can drive or a modified van that will accommodate a wheelchair and architectural renovations for accessibility. Ongoing medical care and follow-up, case management, home cleaner, possible ventilator, toileting, all power bed, patient lift, appropriate orthoses, portable ramps, wheelchair accessories, wheelchair maintenance.
Injuries to the lower cervical nerves, function is determined by the corresponding nerves in the arms and hands. All injuries at the cervical spine will result in loss of functional use of the lower extremities in addition to upper extremity losses.
When injury occurs to C5, a person may be able to raise their arms and bend their elbows. A complete severance at the C5 level will result in total paralysis of the wrists, hands and legs. An incomplete injury may result in some minimal use of the wrist and hands and may require orthosis to assist with movement. The injured person will require assistance with most activities of daily living, as well as a power chair.
Injury at the C6 level will affect wrist extension, at this level, a complete injury will result in paralysis of the hands, trunk and legs. The individual will be independent in transfer with assistive equipment. The injured person may be able to drive an adapted van, if so, they will require driver training, some independence with activities of daily living but will need the assistance of a home health aide.
At the C7 level, there will be movement of the shoulders and they should be able to straighten the arms. They may be able to drive an adapted vehicle but will have no use of the legs and little or no voluntary control of bowel or bladder. They may be independent in transfer, such as getting in and out of the wheelchair or bed with appropriate assistive equipment. May be independent in some activities of daily living but will require a home attendant.
C8 damage will result in difficulty with some hand movement but should be able to grasp and release larger objects. They may be able to do most activities of daily living but may require assistance with more difficult tasks; little or no control of bowel or bladder, in addition to loss of use of the lower extremities.
The thoracic spinal nerves are responsible for the muscles of the trunk and back. Injury in this area usually results in paraplegia (loss of the use of the legs). There is little or no control of the bowel and bladder, but the individual should be able to self-catheterize. At this level, they should be able to use a manual wheelchair if they have the upper body strength to self-propel; otherwise, may require the use of power wheelchair.
Injuries to the lumbar spine usually result in the loss of voluntary control of the bowel and bladder. They may require the use of a manual wheelchair (or powerchair dependent on upper body strength). Loss of function is usually to the legs and hips. Some are able to walk with the use of braces, dependent of the level of damage and whether the injury is complete or incomplete.
Injury to the sacral spine will result in little or no voluntary control of the bowel or bladder. There may be some loss of function in the hips or legs, but most will be able to walk.
In order to fully understand the nature and significance of the spinal cord injury, life care planners turn to medical reports and CNS evaluations. Three important evaluations are the ASIA (American Spinal Injury Association) Impairment Scale, the Katz Index of Independence, and the Functional Independence Measure (FIM). The ASIA Impairment Scale identifies the degree of spinal cord injury (how much function is preserved below the level of injury).
The Katz Index of Independence in Activities of Daily Living ranks six functions of independence in activities of daily living; bathing, dressing, toileting, transferring, continence, and feeding. Each of the activities is rated as independent or dependent.
The Functional Independence Measure (FIM) measures a person’s disability with respect to the amount of assistance required in activities of daily life, as well as measuring the person’s cognitive response to the disability. The FIM has two subscales, motor and cognition. The motor scales measure abilities in eating, grooming, bathing, dressing, upper body, dressing, lower body, toileting, bladder management, bowel management, transfers – bed/chair/wheelchair/toilet, transfers bath/shower and stairs. The cognition component of the FIM includes comprehension, expression, social interaction, problem solving, and memory. The FIM is typically used at the beginning of care and at the end of a rehabilitation.
Spinal cord injuries are complex and require the life care planner to understand the challenges and multiple considerations of the individual who has sustained a spinal cord injury. Consultation with medical professions, as well as the use of assessment scales help determine the amount and type of assistance needed for daily life activities, household modifications and equipment, supplies and future rehabilitation and medical needs.
HEIDI PAUL, PH.D., CRC, CLCP, LPCC
Associate Professor
Coordinator MS Counseling, Option Rehabilitation
California State University, Los Angeles
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